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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 2000 CODE 1. (A) PROVIDER NUMBER K1 Form Approved OMB Exempt FIRE SAFETY SURVEY REPORT SHORT FORM Medicare ­ Medicaid 2. NAME OF FACILITY 1. (B) MEDICAID I.D. NO. K2 Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. (A) MULTIPLE CONSTRUCTION (BLDGS) 2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A. BUILDING ________________ B. WING C. FLOOR K3 A. B. C. Fully Sprinklered (All required areas are sprinklered) ________________ ________________ SHORT FORM CHECK HERE K5 Partially Sprinklered (Not all required areas are sprinklered) K0180 None (No sprinkler system) 3. SURVEY FOR MEDICARE MEDICAID 4. DATE OF SURVEY K4 SURVEY UNDER 5. 2000 EXISTING 2000 NEW 5. SURVEY FOR CERTIFICATION OF 1. K8 HOSPITAL 2. SKILLED/NURSING FACILITY 3. IF DISTINCT PART OF HOSPITAL, IS HOSPITAL ACCREDITED? a. YES b. NO IF "2" OR "3" ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW 1. ENTIRE FACILITY 2. DISTINCT PART OF (SPECIFY) _____________________________ 6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY b. NUMBER OF HOSPITAL BEDS CERTIFIED FOR MEDICARE c. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICARE d. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICAID K9: FOR STATE AGENCY USE ONLY A. The facility MEETS based upon: 1. 2. B. TITLE OFFICE Compliance with all provisions Acceptance of a Plan of Correction e. NUMBER OF ICF BEDS CERTIFIED FOR MEDICAID I HAVE CONDUCTED A FIRE SAFETY SCREENING USING THE SHORT FORM: A. B. C. K9 The facility meets all of the items on the form. The facility does not meet all of the items on the form. A complete fire safety survey is recommended. Recommended waivers. 3. The facility DOES NOT MEET THE STANDARD. DATE SURVEYOR (Signature) 8. SURVEYOR I.D. NO K10 REVIEW AUTHORITY OFFICIAL (Signature) TITLE OFFICE DATE Form CMS-2786S (02/2013) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Name of Facility ID PREFIX MET NO MET N/A REMARKS 2000 CODE CORRIDOR WALLS AND DOORS K18 2000 EXISTING Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Clearance between bottom of door and floor covering is not exceeding 1 inch. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. Roller latches are prohibited by CMS regulations in all health care facilities.19.3.6.3 Show in REMARKS, details of doors, such as fire protection ratings, automatic closing devices, etc. 2000 NEW Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between bottom of door and floor covering is not exceeding 1 inch. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Doors shall be provided with positive latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted. Roller latches shall be prohibited. 18.3.6.3 Show in REMARKS, details of doors, such as fire protection ratings, automatic closing devices, etc. VERTICAL OPENINGS K20 2000 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5, 8.2.5.6, 19.3.1.1. If all vertical openings are properly enclosed with construction providing at least a two hour fire resistance rating, also check this box. Form CMS-2786S (02/2013) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Name of Facility ID PREFIX MET NO MET N/A REMARKS 2000 CODE If enclosures are less than required, give a brief description and specific location in REMARKS. 2000 NEW Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and buildings up to three stories in height.) An atrium may be used in accordance with 8.2.5.6, 8.2.5, 18.3.1.1. If enclosures are less than required, give a brief description and specific location in REMARKS. SMOKE COMPARTMENTATION AND CONTROL K23 2000 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients. 19.3.7.1, 19.3.7.2 2000 NEW Smoke barriers shall be provided to form at least two smoke compartments on every floor used by inpatients for sleeping or treatment, and on every floor with an occupant load of 50 or more persons, regardless of use. Smoke barriers shall also be provided on floors that are usable, but unoccupied. 18.3.7.1, 18.3.7.2 K28 2000 EXISTING Door openings in smoke barriers shall provide a minimum clear width of 32 inches (81 cm) for swinging or horizontal doors. 19.3.7.7 2000 NEW Door openings in smoke barriers are installed as swinging or horizontal doors shall provide a minimum clear width as follows: Provider Type Hospitals and Nursing Facilities Psychiatric Hospitals and Limited Care Facilities Swinging Doors 41.5 inches (105 cm) 32 inches (81 cm) Horizontal Sliding Doors 83 inches (211 cm) 64 inches (163 cm) 18.3.7.7 Form CMS-2786S (02/2013) Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Name of Facility ID PREFIX MET NO MET N/A REMARKS 2000 CODE HAZARDOUS AREAS K29 2000 EXISTING One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Area a. Boiler and Fuel-Fired Heater Rooms c. Laundries (greater than 100 sq feet) d. Repair Shops and Paint Shops